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COUNTY Dutchess
CIT',TuWN Wappinger
~~~~kCRT 1368
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STATE OF NEW YORK
DEPARTMENT OF HEALTH
AFFIDAVIT, LICENSE and
CERTIFICATE OF
MARRIAGE
FROM THE GROOM
David G. Adler
MIDDLE CURRENT SURNAME
~
I
STATE FILE NUMBER
(THIS SPACE FOR STA TE USE ONL Y)
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L 0 SUPPLEMENTAL FILE
I A FULL NAME
FROM THE BRIDE
Jennifer L Adler
FIRST MIDDLE CURRENT SURNAME
B. BIRTH NAME (MAIDEN NAME). IF DIFFERENT Holt
C SURNAME AFTER MARRIAGE Adler
(OPTIONAL - SEE REVERSE) 100 64 1569
D SOCIAL SECURITY NUMBER --
12 RESIDENCE ANY B. Dutchess
(STATE) ~ (COUNTY)
C CHECK ONE 0 CITY LI TOWN 0 VILLAGE
~~~CIFY Poughkeepsie
D. STREET ADDRESS 6 F Hudson Harbour Drive ZIP 12601
E IS RESIDENCE WITHIN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES d NO
06 /26 /1970
DA Y YEAR
FIRST
11 A. FULL NAME
D-
N
B BIRTH NAME. IF DIFFERENT
C SURNAME AFTER MARRIAGE
(OPTIONAL - SEE REVERSE) 061-7') -685')
o SOCIAL SECURITY NUMBER "- "-
2 RESIDENCE A. N Y B Dutchess
ISTATE) (COUNTY)
C CHECK ONE 0 CITY r1 TOWN 0 VILLAGE
~~~CIFY Pouqhkeepsie
D STREET ADDRESS 6 F Hudson Harbour Drive ZIP 12601
E IS RESIDENCE WITHiN LIMITS OF CITY OR INCORPORATED VILLAGE? 0 YES Ii NO
02 / 14 / 197
MONTH DAY YEAR
3 A
AGE 29
13.8. DATE OF BIRTH
13 A. AGE 32
3B. DATE OF BIRTH
MONTH
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4 EMPLOYMENT
A USUAL OCCUPATION Chef
B TYPE OF INDUSTRY OR BUSINESS Traphagen Restaurant
5 PLACE OF BIRTH Valley Stream, New York
ICITY. STATE'COUNTRY IF NOT USA)
14. EMPLOYMENT
A. USUAL OCCUPATION Accountant
B. TYPE OF INDUSTRY OR BUSINESS Unemployed
15. PLACE OF BIRTH Cold Spring, New York
ICITY. STATE'COUNTRY IF NOT USA)
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6. FATHER
A. NAME Glenn Adler
B. COUNTRY OF BIRTH USA
7. MOTHER
A. MAIDEN NAME Lori Nafis
B. COUNTRY OF BIRTH USA
8 NUMBER OF THIS MARRIAGE 1
9 PREVIOUS MARRIAGES
A NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
16. FATHER
A. NAME Paul Holt
B COUNTRY OF BIRTH USA
17. MOTHER
A. MAIDEN NAME Dolores Napoleon
B. COUNTRY OF BIRTH USA
18. NUMBER OF THIS MARRIAGE 1
19. PREVIOUS MARRIAGES
A. NUMBER OF PREVIOUS MARRIAGES WHICH ENDED BY
DIVORCE CIVIL ANNULMENT
o 0
DEATH
o
B HOW DID LAST MARRIAGE END? (3) 0 DIVORCE
(3) 0 ANNULMENT
/ /
(21 D DEATH
B. HOW DIO LAST MARRIAGE END? (31 0 DIVORCE
C DATE LAST MARRIAGE ENDED?
C DATE LAST MARRIAGE ENDED?
(3) 0 ANNULMENT
/ /
(2) 0 DEATH
MONTH DAY YEAR
o ARE ANY FORMER SPOUSE(S) ALIVE? 0 YES 0 NO
20. IF PREVIOUSLY DIVORCED OR ANNULED. PROVIDE THE FOLLOWING INFORMATION
DATE OF DECREE PLACE ISSUED AGAINST WHOM
(MONTH, DAY, YEAR) (CITY, STATE/COUNTRY, IF NOT USA) SELF SPOUSE
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1ST
2ND
3RD
4TH
I, being duly sworn, depose and say, at to
as to my right to enter into the marri e stat
21 SIGNATURE OF GROOM ~
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23 SUBSCRIBED AND SWORN TO BEFORE ME
SIGNATURE OF TOWN OR CITY CLERK ~
This license authorizes the Iljl\rriage in New York State of the bride and groom named above by any person authorized
Relations Law 911 to perform arriage ceremonies within New York State. THIS LICENSE VALID IN NEW YORK STATE ONLY.
If checked, this license is to be used only for the purpose of a second or subsequent ceremony.
~ 24 TOWN OR CITY CLEflK 25. A. SOLEMNIZATION PERIOD BEGINS
} NAME (PRINT) Glona J Morse
{TIME MONTH
SEAL SIGNATURE ~
\- ~ MA~{f~cfd 1120AM 07
-v- PM
STREET ZIP
I CERTIFY THAT I SOLEMNIZED
THE MARRIAGE OF THE PER.
SONS NAMED ABOVE ON THE
DATE AND AT T AND
PLACE IN
YEAR
DATE
by New York Domestic
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28 PLACE WHERE MARRIAGE OCCUR~ ~ ,..
A. STATE NEW YORK B. COUNTY~
Ii-
NAME (PRINT)
SIGNATURE ~
DOH-98 (11/98)
ESTADOS UNIDOS MEXICANOS
REGISTRO CIVIL
No. DE CONTROL
O.R. 44296
EN NOMBRE DEL ESTADO L1BRE Y SOBERANO DE QUINTANA ROO
Y COMO OFfVil1'kJIClfJAL 08 DEL REGISTRO CIVIL, CERTIFICO QUE EN EL L1BRO DE MATRIMONIOS DEL
ARCHIVO SE ENCUENTRA ASENTADA EL ACTA QUE CONTI ENE LOS SIGUIENTES DATOS:
OFICIALlA No. L1BRO No. ACTA No. FOJA LOCALIDAD FECHA DE REGISTRO
08 02 398 43612 CANCUN 28 107 12001
MUNICIPIO I ENTIDAD FEDERATIVA: QUINTANA ROO
BENITO JUAREZ
ACTA DE MATRIMONIO
DA VID GEORGE ADLER - - '. - - - - - - - - - -
NOMBRE(S) PRIMER APELLlDO SEGUNDO APELLlDO
LUGAR DE NACIMIENTO NORTH V ALLEY STREAM ------------..
LOCALIDAD MUNICIPIO 102 173
NUEVA YORK E. U.A. NORTEAMERICANA 14
....
ENTIDAD PAIS NACIONALlDAD FECHA DE NACIMIENTO
( CRIP
)
DATOS DEL CONTRAYENTE
DATOS DE LA CONTRAYENTE
( CRIP
)
JENNIFER LEIGH
HOLT
NOMBRE(S)
LUGAR DE NACIMIENTO
PRIMER APELLlDO
SEGUNDO APELLlDO
COLD SPRING
NUEVA YORK
E. U.A.
MUNICIPIO
NORTEAMERICANA
26
70
LOCALIDAD
ENTIDAD
PAIS
NACIONALlDAD
FECHA DE NACIMIENTO
( ESTE CONTRATO DE MATRIMONIO ESTA SUJETO AL REGIMEN DE:
SOCIEDAD CONYUGAL
)
SE EXTIENDE ESTA CERTIFICACION, EN CUMPLlMIE. NTQ Q.E;1,. ARTICULO
CODIGO CIVIL VIGENTE EN EL ESTADO, EN... CANt.;uN
QUINTANA ROO, A LOS 28 DIAS DEL MESDE JULIO
DaY FE.
635 DEL
DE ...2001
( SELLO )
08
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Mun.{::L'i': ':,;,l~ Jll~r(l7.
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C. JUAN CARLOS RAMIREZ MOHEDANO
( NOMBRE )
T:
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